Académique Documents
Professionnel Documents
Culture Documents
REGISTRATION
(limited to 40 campers)
Name _________________________________________
Adult S M L XL
EMERGENCY C0NTACTS
Parent/Guardian: _____________________________ Phone: ___________________
Parent/Guardian: _____________________________ Phone: ___________________
Other: ________________________________________ Phone: ______________________
Order in which to be called: Mother _______
Father __________
Other __________
PAYMENT
The cost of the camp is $40 per camper. For those unable to pay the full amount, we ask that
you contribute whatever your budget can handle between $15 and $40 per camper. If possible,
include your entire payment with your registration (or at least $15 per camper).
I have enclosed $ ____________.
No ______
Names of person(s) allowed to pick up camper (BE SURE YOU OR OTHERS BRING ID!)
_____________________________________________________________________________
_____________________________________________________________________________
No _____
IMMUNIZATIONS
Please list dates or include separate form from school or doctor.
Dose Admin.
DPT
Date Admin.
Dose
Date
1st __________
MMR
1st __________
2nd __________
2 nd __________
3rd __________
OPV
1st __________
st
Tetanus (td)
1 __________
2nd __________
latest__________
3rd __________
Meningitis if given __________________________
Hepatitis B
1st __________
2nd __________
3rd __________
RELEASE INFORMATION
My signature below certifies and gives permission that:
1. All information given is correct.
2. Photos of my child can be used in camp publicity.
3. My child can be transported for camp activities.
4. My childs medical records can be released in case of illness/injury.
5. In the event I cannot be reached, I give permission to the Physician selected by the Fowler
and Bellevue Reformed Church staff to hospitalize, select treatment for, order medications,
anesthetize, and/or perform surgery on the child named above.
Parent/Guardian Signature:______________________________________________________
Date:________________________________________